Saturday, 27 August 2011

A friend posted something on FB about celebrating the anniversary of female suffrage.

The article was from an American newspaper dated yesterday because the 26 August 1920 was when women in America got the right to vote. (Link here and if you are really suffering from insomnia check out the comments)

Well that's good - America preceded the UK by some eight years. But being in a peevish mood I moaned about Americans celebrating their 81st anniversary of female suffrage. Hardly a 'special' anniversary, and as far as I could read - no-one died to further the cause of female suffrage in the USA.

One of my friends pointed out that we can all be parochial and it is good to share our experiences and history from different countries (OK she didnt say all that but I think that's what she meant - sorry A, if I misunderstood). I hold my hand up straightaway and confess to being parochial.

But who, British, has not sat in history classes studying 19th century social history for 'O' level without learning about the suffragettes? And that Emily Davison was killed under the king's horse at Epsom? And to be really honest, who remembers her name? - rather, we all remember the Pankhursts. If Emily died in the cause of women's suffrage, other women went to prison, went on hunger strike, and were force fed with tubes into their stomachs. These women fought and suffered to ensure that other women got the vote.

So my view of female suffrage is based - narrowly - on what I learned about my own country's history. The same friend who commented about our parochial mindsets also pointed out that perhaps the American suffrage was needed by the temperance movement to achieve Prohibition. Another interesting thought.

Anyway, moving swiftly on away from the UK and the USA - and onto New Zealand. For those of you who don't know, New Zealand has been a trail blazer in equal rights for women. Women in NZ were granted the right to vote back in September 1893, voting in their first election in November later that year.

Not only that but NZ can claim to having a woman mayor in the same year, the first time the office had been held anywhere by a woman in the British Empire. Good one New Zealand. For anyone interested in the right to vote, here is an interesting list of when women were granted suffrage across the world. I say granted, because - that's what it was/is - something that should be a right but happens to be granted by those in power who finally succomb to acknowledging they can no longer wriggle out of it. list

Back to NZ. If NZ was hot off the mark with giving the women the right to vote, they were hellish slow in giving women the top job of head of state - prime minister. Even the UK had managed it during the 20th century before NZ, although not, of course America, which still awaits a female leader in the 21st century. Confronting their prejudices head on, Americans chose a half black man in preference over the incredibly brilliant Hillary Clinton.

Hell, who wants a bright woman running the world? I did. And I was gutted when a load of my American feminist friends seemed to think that choosing a black man was such a right-on statement of their principles when they could have voted for Clinton. Bollocks. They should have worried less about their right-on racist-friendly credentials and just gone for the right person. I thought Clinton had some excellent ideas, was sound on so many issues and was such a serious contender to lead America - and truth be told, to lead the world, because let's not deny it, that's what America does. My perspective wasn't about - let's back the woman because she's a woman - or I would be espousing Michelle Bachmann or Sarah Palin as super duper candidates for anything and everything. Actually I wouldn't choose either of them to be the cashier at my local supermarket but that's just my view.

NZ's first woman prime minister was Jenny Shipley, came to power in 1997 and served until 1999. She was succeeded by Helen Clark who served until 2008. But if NZ was slow off the mark to have a woman prime minister, the country still managed to hit the record books as one of the few countries in the world to have had two female heads of government, and one of only two countries to have two female heads of government directly succeed the other.

A couple of soundbites about Shipley. A member of the NZ National Party, she was the first NZ PM to attend the gay and lesbian hero parade, and achieved the lowering of alcohol purchase age from 20 to 18. She now has business interests in China.

And on Clark - she was a member of the Labour Party and served as prime minister for three terms. In 2009 she became Administrator of the UN Development Programme - and the first woman to lead this. Another milestone for Kiwi women.

I had better mention Australia as they are pretty near neighbours. After NZ granted the vote to women back in the 19th century, the Australian states followed pretty soon afterwards. At this point I have to mention Julia Gillard - how many of you (non-Antipodean friends) have heard of her? I hadn't. She is the first woman prime minister of Aus. Born in Wales, I might add, Barry, actually. Only the second prime minister of Australia who was born outside Aus.

Gillard has some interesting views. Pro-choice ie supporting women's rights to abortion, but, she doesn't support gay marriage. She wants a sustainable Australia - which translates to anti-immigration. And she wants a republican Australia. Just to add, Quentin Bryce is the first woman Governor General of Australia. (Who she? I hear you ask)

When I was a kiddy in the 70s, women prime minsters were all the rage. Bandaranaike ( I never did know her first name), Indira Gandhi, and Golda Meir. I was indoctrinated with my father's skewed views - 'better a bad prime minister than a good woman pm'. This from the man who became a devoted follower of Margaret Thatcher. Of course, he dismissed Bandaranaike, Gandhi, and Meir. They came from third world counties or something like that.

Hello daddy. These third world countries, Sri Lanka (then Ceylon), and India, that were inhabited by wogs, happened to be part of the British Empire or supported by it, and well, the truth is, their populations weren't as sexist as you were. Electing a woman as head of state was not a marker of a country's stupidity. Israel was clearly an anomaly in the scheme of things, as my father had some good Jewish pals, and obviously they would never have knowingly voted for a woman prime minister.

But looking at the list of women leaders in the world, I am amazed to see that of the early prime ministers, the first one was an acting German Jewish woman in the Ukraine - Evheniya Bohdanivna Bosch, the next three were the trio I mentioned above, then, there was Élisabeth Domitién, from the Central African Republic, who was premier minister from 75/76 - I had never heard of her - and then, we get to Margaret Thatcher. Only the sixth woman prime minister in the world. And to be really blunt, the first one from an influential western country.

Saturday, 6 August 2011

Before I started working in the health service, I had no idea what the concept meant. I figured it meant you either lived for ever or you died. But on joining the health service, I learned pretty quickly.

An 80% survival rate doesn't mean that eight of ten people will live for ever and a day after being diagnosed with X illness or disease. It refers to a five-year period. Not that you will necessarily live out your so-called normal life until 70 or 80 or 90 or whatever. Just that you have a good chance of being alive five years after diagnosis. And that doesn't even get into the issues of reoccurrence or metastatic cancer for example.

I must say as with a lot of communication, the NHS (UK health service) has improved its presentation of statistics. You can actually look up five year survival rates for cancer. - Here for anyone interested. If you look at that cursory weblink, you will note that breast cancer survival rates are above 80% which is a good thing. Similarly the rate for testicular cancer is 97% and prostate cancer is 80%. Malignant melanoma is between 80 and 90%.

Why then are people jumping on bandwagons to promote our awareness of any of those cancers?? Pancreatic cancer has a survival rate of less than 4%. Liver cancer is similar - the graphs I looked at didn't mention the rate and also used one year survival rates because they look better. Lung cancer is around 8%. As is oesophageal cancer. Stomach cancer - 15%. Ovarian cancer is one of the baddies too but that is a whopping 40 odd %. Colorectal is one of the three 'common cancers' along with lung and breast. The survival rate for colorectal is just over 50% - that is really poor. When do we hear about any of those cancers??

Pause for a quick anecdote. We sold one of our houses to a medic. An eye surgeon. He had a Land Rover so mostly Partner and he talked Landies. But at some point they flipped onto a clinical discussion and Partner pointed out that survival rates were based over a five year period. Eye surgeon/Landy friend was bemused and asked how Partner knew that. Pretty obvious really given the fact I was responsible for cancer services. Then 'Well yes but not many people know that." Maybe not, but they should. Telling people they have a survival rate of 80% or 20% or whatever - without telling them it is over five years is downright misleading. The Mayo clinic - as ever - has a good and clear article here.

Now, while I am on about survival rates, I need to mention lead time bias. I was rather up on this at one point and could quote every relevant piece of research under the sun. Put very simply - lead time bias is about the difference between the start of your illness and when it is diagnosed or discovered, and the perceived impact earlier detection has on survival rates. Actually for once, Wiki puts it incredibly well. Check it out here.

Basically for example, if you are diagnosed with breast cancer from the screening programme, you may well find out that you have cancer sooner than you would if the cancer was diagnosed when symptoms appeared (normally small lumps in the breast/axilla areas). When the cancer is diagnosed doesn't affect the overall life expectancy (and therein lies a whole issue about waiting times) but it can skew survival rate figures if it is detected early. If you are diagnosed earlier - you may well 'appear' to live longer. But life expectancy isn't or shouldn't be dated from diagnosis, it is from when the disease starts. There is a huge difference there. Anyway, check out the Wiki link because the diagram on there explains it very simply. Wiki also points out the additional impact of mental anxiety of earlier diagnosis.

Let's go back to survival rates and lead time bias. For women diagnosed with breast cancer in 2001-2006, five-year relative survival rates have reached 82% (England only) compared with only 52% thirty years earlier in 1971-75. Ten year survival rates for women diagnosed with cervical cancer have improved from around 46% in the 1970s to 64% for the latest period.

Thursday, 4 August 2011

Oh dear. It is that time of year where women start posting crass comments on facebook about the colour (of their bra), the state (of their hair), where they like it (left their handbag) and now the latest one, which I can't possibly reveal - or remember - what it is.

If anyone is interested mine were white, long and messy, and hidden under piles of clothes.

All to raise awareness of breast cancer.

Do you know anyone who hasn't had breast cancer? Unlikely.

UK stats for 2008 say that of all cancers in women, 31% are for breast cancer. Or a different statistic says that the risk of developing breast cancer is i in 8, ie 12%. You can do anything with statistics.

I have met some great patients with breast cancer, have some lovely friends who have had breast cancer, and I can't begin to know how they manage to smile and keep going every day after their crap treatment, and everything that really goes with a cancer diagnosis.

But what gripes me about this facebook trivialisation is that I don't see how it helps anyone.

Why does making a sexually suggestive comment raise awareness of breast cancer? Why do we need to raise awareness of breast - or any other - cancer?

What we need to do is generate a little more knowledge and empathy.

There is nothing funny or light-hearted about being diagnosed with a potentially life-threatening disease.

Openness, honesty, and supporting friends seems to me to be a far better way to go.

Three friends come to mind immediately - one who has set up a facebook support group for cancer survivors and caregivers, another, who has posed for photographs bald and naked. Another has used her talented skills to help other women with chemo problems find the right wigs while they are going through hair loss.

Wednesday, 3 August 2011

Whether it is funded, or not funded, by government or insurance companies - or you pay for it privately - it is still rationed because money is finite. It is just not possible to fund every medical treatment under the sun, and people who complain about that are amazingly naive. The difficulty comes when deciding exactly what to ration and how to do it.

Here are a few random tales, all of which were publicised for whatever reason at some point so I'm not breaking any confidences. Let's start with breast implants. I was happily sitting at my desk when the 'phone rang. It never stopped all day. When I put it down it rang again, and my secretary was in and out all day with messages from newspapers, radio and tv stations all wanting me to call them back.

Why? Because one of our local GPs had referred a patient for breast enlargement so that she would be more successful as a topless model. Some background. Well, naturally the NHS isn't - or wasn't - some sort of support agency to the Job Centre. It's prime function is not one that offers surgery to anyone and everyone who feels they might do better in life if they were 'better' looking. Or perhaps, looked different would be a more appropriate description.

And indeed, being referred for surgery to help her topless modelling career wasn't how the doctor got the referral through. His patient was suffering from low self-esteem due to her small breasts. If she didn't have depression then, no doubt it would set in later. The operation cost slightly over two grand. Not huge in the scheme of things.

Working in public sector press and media I found it useful to not have a view on things. It made it much easier to churn out my party line, and not get involved in any discussions and - say the wrong thing. This GP wasn't a fundholder so it fell to the health authority to fork out the £2K+ - and that's why I spent all day politely telling every media caller that a) we couldn't go into detail about individual patients and b) it was up to every doctor to exercise their clinical judgement appropriately when referring patients for surgery etc etc etc. I was quite happy with this line and it was dutifully repeated by everyone who called me when they published or broadcast it.

Some years later on, I can allow myself an opinion. In no particular order:

1) I still think it is up to each and every doctor to decide what is the right treatment for their patient. Up to the patient then to decide whether to take it up.

2) Suffering from lack of self-esteem and/or depression is not good. Just because mental illness isn't obviously visible doesn't negate from the seriousness of the illness and the trauma that people suffer. People who are mentally ill and fall in and out of big black holes do not have a good time - and like other chronic illnesses - it is always with them.

3) I have probably also had low self-esteem from having small breasts, although becoming a topless model wasn't high on my list of career choices. It is not nice to pass people in the street and hear them saying they can't decide whether you are a girl or a boy. Not helped by the fact I was tall and had shortish hair. Then there are the ones who quite bluntly tell you that you have small breasts, that you are flat-chested, that you look like a boy, and that you don't look remotely sexy. And this last point is the issue.

What on earth is it about our (male) society that imposes such conditioning on women they feel they need to have surgery to get bigger breasts? Or that the aspirations of a young woman are to become a topless model? I know that appearances are important and that we are all judged on them. But women are judged in a different fashion.

We all know the ideal woman. She has a slim but curvaceous body. Long well formed pins, reaching right up to her cute and firm arse. Oh, I should add that those pins are immaculately smooth and shaved every day so that a chiffon scarf will drop straight down them. She has long sexy hair, big eyes, and a beautiful Colgate pearly white smile. And naturally her breasts are NOT small, but just the perfect size, firm with a suitable amount of cleavage for men to peer down.

Who creates this ideal woman? Men. She's not a woman. She's a sex object. And anyone who wants breast enlarging surgery is sadly conditioned to believe all this. They are buying into the male fantasy of the perfect woman sex object. And they aren't doing any favours to women who don't want to be judged on the size of their breasts. A few years ago I met someone who had undergone breast enlargement and had her eyes tucked. She looked top heavy and the skin around her eyes was so tight. I think she could have spent her partner's money more wisely.

So these days, I would be sadly disappointed to hear about any GP referring their patient for breast enlargement. For whatever reason. It seems to me to be treating the symptom and not the cause, but maybe that's what medics do. Some helpful counselling and assertiveness skills would be a lot more helpful - IMO.

Some of the longest waiting lists in my NHS days were for plastic surgery - and the two critical areas were for burns, and for reconstructive surgery following breast cancer mastectomies. Technically I suppose one could argue that reconstructive surgery is similar to breast enlargement and could well involve self-esteem issues - but at the end of the day, I don't think there is any comparison between a woman who has gone through surgery and chemotherapy, that was not something of their choosing and a young woman wanting bigger tits so she can appear on page 3. Incidentally, I read later that her modelling career didn't last long. So, in terms of rationing - I would not want to see the NHS spending money on breast enlargement for women, whether for self-esteem issues or not. There are other ways to gain self-esteem.

Onto another controversial area. Fertility treatment. We decided that we needed to introduce criteria for this service. Which is another way of saying rationing the service. We put a paper to the board with extremely tight criteria. The chief executive had primed the chair about it. She was expected to approve the paper.

But she had been lobbied by some of the local fertility action groups. And - she told me in confidence, and quite a few others as well - that she had been unable to have children back in the days when fertility treatment didn't happen on the NHS. So when it got to the critical moment at the board meeting - she deferred the decision for consultation with our local groups. Great, another two months of indecision.

The proposal got watered down of course. The age limit went up to nearly 40 (conception is less likely as you get older so treatment for older women was less effective), we had a clause requiring residency in the area for a couple of years, something about a stable relationship, and there was probably something about only three goes at it, or something similar.

Out of those of us who originally discussed it, there was me - the only woman, and some 40 or 50 year-old men, who had children. Not exactly the most empathetic group for infertile women. Yes, we heard about the angst. The emotional trauma for women who couldn't fulfil their lives by not having a baby. The sheer mental distress of it all and how it affected their relationships. And how wonderful it was for those who did eventually conceive. That's great. Because in a world of limited resources - you stand up and tell someone who is being deprived a few months of life for an expensive cancer drug that your need for an IVF baby comes first. I couldn't.

Next up came screening for Down's Syndrome. But by then I think we had lost the will to ration, and this really was just a long-winded exercise to write down some firm criteria about when and whether pregnant women should have blood tests, ultrasound tests or amniocentesis.

But a few years later, with a change of directors - rationing picked up its lively head again and we decided to hold a public meeting and discuss how to spend our so-called development monies. These were peanuts in the scheme of things as virtually 90% of the budget is already spoken for as soon as it is allocated. Those of us responsible for some of the key services - maternity and child health, elderly services, mental health services, cardiothoracic medicine, and cancer - were asked to present our 'case' for investing in our service.

I have to say it was rather a tabloid exercise. Asking people to decide how to spend money based on a few presentations over a couple of hours? I didn't present my case. I asked a clinical director for cancer services and a breast cancer patient to make the case. I figured they could do a lot better than I could have done. They did. We 'won' the debate. Always choose the right people to give the message. And there ends my mixed post on rationing.

In theory it should be based on clinical effectiveness - ie don't provide services that don't work. Secondly, don't provide expensive services that either don't work or when there is a cheaper and as effective service available.

Most people don't want to accept, or don't like the fact that rationing exists. They also don't want to make the decisions themselves but they sure as hell want to blame those of us who can't make a health service budget into the bottomless pot of gold at the end of the rainbow.